It's been widely and falsely accepted that so called Attention Deficit and Hyperactivity Syndrome (ADHD) is biologically and neurologically determined and has nothing to do with parenting styles, poor parenting or difficult family environment. While this scientifically unsupported claim has been primarily promoted by psychiatrists, psychologists haven't hesitated to jump into the bandwagon either. As comprehensively outlined in 11 American psyhologists' letter (Galves et al., 2003) to American Psychological Association (APA) on May 15, 2003, following APA's distribution of ADHD brochure in which ADHD presented as a biological and neurological disorder that has no connection what so ever with family environment, "this is disenfranchisement of our particular perspective on ADHD from our own professional organization." (p. 19).

This is sheer politics. Not science, just politics. Basically there are two factors underlying this politics. One is the obvious pharmaceutical industry together with the institution of psychiatry, the other is the untouchable sacred family. Not only for ADHD, this is true for any known psychological suffering. Take for example Bateson et al.'s (1956) 50 years old "double-bind" theory on schizophrenia. As comprehensively documented in Koopmans' review (1997), it's never been truly scientifically refuted, yet the institution of psychiatry not only keep ignoring it, also holds a belief that schizophrenia is a "brain disorder".

Simply no. Neither schizophrenia nor ADHD nor any psychological suffering is a brain disorder. Even the diagnosis of ADHD is far from being valid as promoters of neuro-biological aetiology confessed: "Because of the inability to demonstrate consistent neurobiological differences between hyperactive children and normal controls, the validity of the hyperactivity syndrome remains controversial." (National Center for Biotechnology Information, 2004). There is not a single research study up to date that clearly verified that any psychological suffering is a brain disorder. No objective biological finding, no objective brain mapping. Findings that show an association between "abnormal behaviour" and brain do not conclusively prove that there is a causal relationship between the two. It is widely known that an association between two entities doesn't mean that there is a causal relation between them. Yet as seen in one of the most publicized study (Zametkin et al., 1990), very poor findings derived from adults were promoted in and out of psychiatric circles as "the biological evidence for ADHD is found". Besides, these poor findings haven't been replicated even by Zametkin himself (Zametkin et al., 1993) in a study with adolescents (on the web site of National Center for Biotechnology which mentioned above, Zametkin et al.'s 1990 study is listed, but not the 1993 study!).

While these biological and neurological claims are far from being scientically verified, psycho-social explanations for ADHD and for any psychological suffering have been solidly presented in the psychological literature. Yet the majority of psychologists together with almost all psychiatrists are willingly chosing to accept the bio-neurological explanations.

As listed in the letter to APA (Galves et al., 2003) the scientific evidence demonstrates that ADHD is significantly associated with poor parenting, difficult family environments and inhumane and oppressive school and community environments. Here I propose to re-list a few of the characteristics of parenting and family environments that have an association with the behavioral characteristics of ADHD with some additions of my own.

- Family instability, differences in pressure for achievement in the family, provision for early learning, disciplinary practices, interest in the child’s schooling, negative and pessimistic perception by parents of the child’s academic and intellectual competencies accompanied by decreased expectation levels and decreased desire to participate with the child in learning activities (Lambert and Hartsough, 1984).

- Mothers’ use of criticism and general malaise in parenting (Goodman and Stevenson, 1989).

- Father’s hypercritical and destructive attitude, inconsistent, impatient and pressuring parenting approach and mothers who are judged to be emotionally disturbed (Thomas and Chess, 1977).

- Parents who use aggressive behavior, indiscriminate aversiveness and submissiveness or acquiescence toward their children during management encounters (Patterson, 1982).

- Experiences of high level of stress in parenting and feelings of lower self esteem (Goldstein and Goldstein, 1990).

- Mothers who were critical of their difficult babies during infancy and showed lack of affection for them continued to be disapproving and tended to use severe penalties for disobedience during the primary school years and assessed their children’s intelligence as low (Ross and Ross, 1982).

- Overinvolved parenting style is associated with the child's decreased perception of control over events (Hudson, 2001).

-Evidence suggests that the presence of ADHD in children is associated to varying degrees with disturbances in family and marital functioning, disrupted parent-child relationships, specific patterns of parental cognitions about child behavior and reduced parenting self-efficacy, and increased levels of parenting stress and parental psychopathology, particularly when ADHD is comorbid with conduct problems (Johnston and Mash, 2001).

There are two areas of research -attachment and trauma- that have shown the impact of early familial experience on the traits characteristic of ADHD, and one area of research -parenting styles- that have successfully shown how powerful the parenting styles could be to produce and overcome the problems related to ADHD.

It's been documented that there is a significant relationship between the quality of parent-child relationships in the first months of life, the quality of attachment at one year of age and the school performance, sociability, levels of anxiety and even general health of children in primary and secondary school (Bowlby, 1988; Crittenden, 1992; Cummings and Cicchetti, 1990; Goldberg, Muir and Kerr, 1995; Holmes, 1995).

Indeed the behaviors that are used to diagnose ADHD can be seen as the natural and understandable reaction of an insecure child to a stressful situation (Clarke et al., 2002; Erdman, 1998).

On the other hand, research studies on trauma suggested that traumatic experiences early in life had a great impact on the ability of victims to adjust their emotions (van der Kolk, McFarlane and Weisaeth, 1996; Herman, 2000). Trauma victims almost always display impulsiveness, high activation, or exactly the opposite, very low activation. These are precisely the behaviors that are used to diagnose ADHD.

It's also known that the serious effects of trauma are transmitted across generations as seen in children of Holocaust survivors (Rowland-Klein and Dunlop, 1998) which by itself can be seen as a refutation of highly promoted genetic transmission of many psychological disturbances.

Furthermore Deutsch et al. (1982) found that adopted children are much more likely to be diagnosed with ADHD than non-adopted children. This is quite understandable in view of the fact that all adopted children have suffered the trauma of being taken away from their birth mothers and that most of them were raised by over-protective/permissive adoptive mothers (parents).

Parenting Styles

Baumrind's (1967) "authoritative" research study on "parenting styles" is one strong tool to understand developmental problems in a spectrum and indeed problems related to so called ADHD. Although the study has not been designed to look into ADHD syndrome (ADHD was not popular at all in the 60's), it includes almost every feature of ADHD.

Before looking at the details of Baumrind's parenting styles model and how inadvertently it explains the ADHD syndrome, it's worth mentioning the methodological strength of it. It's been repeatedly emphasized that a true diagnosis of ADHD should be done by careful observation of children's behaviours both at home and at school (and also preferably at a neutral location and not just at the doctor's office). However, we all know that only a few psychiatrists and psychologists are in conformity with this basic principle. Whereas in Baumrind's research study, not only the children but also the parents were observed at home and at school.

Based on fourteen weeks of observations, Baumrind identified three groups of children who differed considerably in their behaviour:

Baumrind then interviewed the parents of these children and observed them interacting with their children. She found three distinctive patterns of parenting which were associated with the three groups of children as follows (see Table 1):

Authoritative parenting → Energetic-friendly child

Authoritarian parenting → Conflicting-irritable child

Permissive parenting → Impulsive-aggressive child

Insert Table 1 about here

The characteristics of the authoritarian, permissive, and authoritative approaches to discipline were summarized by Baumrind (1978) as follows:

1) Authoritative parent attempts to direct the child's activities in a rational issue oriented manner. He or she encourages verbal give and take, shares with the child the reasoning behind parental policy, and solicits the child's objections when the child refuses to conform. Both autonomous self-will and discipline conformity are valued. Therefore, this parent exerts firm control when the young child disobeys, but does not hem the child in with restrictions. The authoritative parent enforces the adult perspective, but recognizes the child's individual interests and special ways. Such a parent affirms the child's present qualities, but also sets standards for future conduct, using reason as well as power and shaping by regimen and reinforcement to achieve parental objectives.

2) Authoritarian parent values obedience as a virtue and favors punitive, forceful measures to curb self-will at points where the child's actions or beliefs conflict with what the parents thinks is right. The authoritarian parent believes in keeping the child in a subordinate role and in restricting his autonomy, and does not encourage verbal give and take, believing that the child should accept a parent's word for what is right. Authoritarian parents may bevery concerned and protective or they may be neglecting.

3) The permissive prototype of adult control requires the parent to behave in an affirmative, acceptant, and benign manner towards the child's impulses and actions. The permissive parent sees him- or herself as resource for the child to use as he wishes but not as an active agent responsible for shaping and altering the child's ongoing and future behavior. The immediate aim of the ideologically aware permissive parent is to free the child from restraint as much as is consistent with survival. Some permissive parents are very protective and loving, while others are self involved and offer freedom as a way of evading responsibility for the child's development.

What are the results of these models of discipline for preschool children? As can bee seen in Table 1, it appears that authoritative parents are most effective in controlling undesirable behaviour while authoritarian parents tend to have children who are fearful, unhappy, less assertive, and aimless. Children of authoritative parents are more likely to be self-reliant, explorative, self-controlled, friendly, cheerful, and cooperative while children of permissive parents tended to be the least self-controlled, self-reliant, and explorative of all the three groups.

Surprisingly, many of the behaviours of permissive-indulgent parents’ and authoritarian parents’ children are exactly the same behaviours characteristic to ADHD. The behaviours with two stars in Table 1 are exactly the same as ADHD behaviours. The ones with one star are also similar to ADHD behaviours, but to a lesser degree. Moreover, the children of permissive parents are identified as "impulsive" children, as exactly the same as in ADHD's "hyperactivity-impulsiveness" category.

Being "aimless" as highlighted in italics in Table 1, seems to be the common characteristic of children of both permissive and authoritarian parents.

Indeed, ADHD children who are diagnosed with a checklist that has no scientific validity suffer from primarily "being aimless" (they act with no specific purpose) not from "HYPERactivity". One of the distinct characteristics of children of authoritative parents is "high energy level" (as highlighted with "√" in Table 1) which is desirable. He or she is "energetic" and "purposive" at the same time. As a consequence, the problem DO NOT lie in "high activity level", but in "aimless" activity. It is highly likely that looking only for "high activity level" is the main reason for 86% of 375 rural North Carolina Appalachia children who were decided by "experts" to start taking medication did not fulfill the criteria for ADHD (Angold, Erkanli, Egger, and Costello, 2000). Note that 29% of these children had no ADHD symptoms at all before onset of medication.

Implications

Baumrind's parenting styles model not only explains how parenting styles are undoubtedly associated with the behaviours characteristic to ADHD (regarding aetiology of ADHD), it also shows ways to overcome these problems related to ADHD (regarding remedy).

As highlighted in italics in Table 1, most of the behavioral patterns that energetic-friendly children display are exactly the opposite of the behaviours characteristic to ADHD diagnosed children. ADHD diagnosed children do have problems with their peers, whereas energetic-friendly children don't; ADHD children are not cooperative with adults, whereas energetic-friendly children are; ADHD children are aimless, whereas energetic-friendly children are purposive (and have interest and curiosity in novel situations; i.e., "purposive curiosity", not "wandering about without any specific purpose" as in ADHD children); ADHD children do lack self-control and self-reliance, whereas energetic-friendly children are self-controlled and self-reliant; ADHD children are not achievement-oriented, energetic-friendly children are.

As a social psychologist, who has turned to be more of a practicing psychologist, I propose that the practitioners in the field should focus on how to improve the parenting skils to help the child to develop such bevahiours characteristic to energetic-friendly child.

This should not prove too difficult to implement once the parents free themselves from the "good parent-bad parent" syndrome.

Insert Figure 1 about here

Figure 1 summarizes the basics of being an effective (authoritative) parent. Four dimensions of parenting that clearly helps developing the desired behaviours of children are as follows (Baumrind, 1967, pp. 54-57):

Parental control: consistency in enforcing directives, ability to resist pressure from the child, willingness to exert influence upon the child.

Parental maturity demands: both the pressures put upon the child to perform at least up to ability in intellectual, social, and emotional spheres (independence training) and flexibility in the choice given the child to make his/her own decisions (independence granting).

Parent-child communication: the extent to which the parents uses reason to obtain adaptive behaviour, solicits the child’s opinions and feelings, and uses open rather than manipulative techniques of control.

Parental nurturance: parental acts and attitudes that express love and are directed at guaranteeing the child’s physical and emotional well-being. Nurturance is expressed by warmth and involvement.

Among the four dimensions, "communication" seems to be the crucial one. I strongly believe that the simple implementation of "parental control", as can be seen in "authoritarian parenting", without improving communication skills will not work. It has been noted that lately some psychiatrists with very poor knowledge in psychology advise parents to use strict control on their ADHD children. However, a strict framework with rules and a behaviouristic approach that relies on token economy program (along with poor commucation) might make things even worse. It is possible that this same approach is the reason behind the 1999 MTA study suggesting that behaviouristic intervention didn't work well with ADHD children. Note that MTA study was criticized by one of the inspectors of the study (Pelham, 1999) not only for its behaviouristic approach, but also for its critical methodological flaws. The study was highly criticized by others, too (e.g., Boyle and Jadad, 1999).

Looking at Figure 1 again, priority should be given to communication skills. Following that and supported by my own personal experience with the ADHD children and their parents, I would suggest that maturity demands should be followed by parental control and parental nurturance. Nevertheless, we should bear in mind that all four dimensions should equally be in action at all times.

Negligence and ignorance

I mentioned in the first paragraph of this article, the letter to APA by 11 psychologists which eloquently says "this is disenfranchisement of our particular perspective on ADHD from our own professional organization." (Galves et al., 2003, p.19).

I would personally add that APA and most psychologists, by accepting the psychiatric stance, are being negligent and/or ignorant.

Even before Baumrind's (1967) research study on parenting styles, Becker's (1964) research study entitled "Consequences of Different Kinds of Parental Discipline" clearly demonstrates that children of permissive (detached, indifferent, neglecting, and rejecting) parents become impulsive, goalless, delinquent, disobedient, and aggressive, i.e., all traits characteristic to ADHD.

There are also comparatively recent research studies, albeit few, that demonstrates that ADHD behaviors may represent a developmental phenomenon that is largely preventable:

- In Carlson, Jacobvitz, and Stroufe's (1995) prospective, longitudinal research study, 191 firstborn children were followed from infancy to end of sixth grade. They found that for hyperactive children, intrusive and over-stimulating parenting played a prominent role. The authors proposed that development of early parenting skills and social support would play a preventive role.

- Wilson and Wilson (1996), again in a prospective research study, surveyed parents who joined a community parent training program and compared the outcomes with no participating parents. The program taught a nurturing, but structured child-rearing approach, much in the manner of Baumrind’s authoritative parenting. When the children were surveyed at age four to seven years, participants who followed the principles on which the curriculum was based had a substantially lower incidence of DSM-III-R ADHD criteria (5%) than non-participants (16%).

- Further evidence came from another research study done by Stein (1999). Stein has implemented a novel behavioral approach to managing ADHD behaviors and reported encouraging data on effectiveness of using this approach. Stei2n's "Caregivers Skills Program’s" (CSP) underlying assumptions are different from the conventional behavioral approach. Stein proposes that ADHD children can be trained to develop those behavioral traits they lack, and that effective behavioral management relies upon avoiding material reinforcers, incentives, or token economy programs. Reinforcement for appropriate behavior is stressed, consisting of social reinforcement only. Stein found that 11 of 12 targeted ADHD behaviors improved dramatically or disappeared within four weeks among the 37 children fulfilling DSM-IV criteria for ADHD ages 5 to 11 years. These gains were stable at follow-up one year after intervention.

Concluding remarks

Last year (in 2004) 84 thousand boxes of stimulants were prescribed in Turkey (80% in three big cities, Istanbul, Ankara, and Izmir) which approximately equates to 10 thousand children diagnosed with ADHD.

Psychological circles in Turkey are acting in line with APA's approach to the ADHD issue. Psycho-social interventions are non-existant. Last year the Turkish Ministry of Education together with psychiatrists and assisting psychologists started a project identifying children with ADHD and then refering them to psychiatry clinics. Reluctantly, I have to say, I was the only psychologist who opposed the project. I had already written many essays on ADHD published in various Turkish newspapers and journals and translated the letter to the APA in full length, and although I could not publish it I have nevertheless distributed it widely by e-mail; and from the moment I learned about the project I did my best to intervene with the process. My solitary intervention and success (if it can be seen as a success) seems to have just slowed down the increase rate of consumption of stimulants (from 11% rise in 2004 to 6% rise in 2005). Yet the project is still in action.

As I tried to outline in this article, we already have powerful psycho-social tools to understand the phenomenon and to produce solutions to the problems related to so called ADHD. As I will present the details elsewhere, my research suggests that we can solve the problems related to ADHD solely focusing on parenting styles based on Baumrind's (1967) model. The model is also effective with teachers as brilliantly demonstrated in Wentzel's (2002) study where data gathered from 452 sixth graders.

Having been highly involved in cross-cultural research, my final remarks would be related to cultural issues both regarding Baumrind's model and the ADHD issue. It's been said but not confirmed by research that there is almost no ADHD in Japan. I contacted several Japanese researchers asking for solid evidence for the problem. I've been told that since the problem does not exist in their social context it did not seem necessary to research it. However, I believe that we still need to do cross-cultural research in order to understand the phenomenon in every aspect and to refute bio-neurological claims. Baumrind's model applied to the Chinese culture (Chao, 1994, 2001; Chen, 1998; Chen et al., 1997, 1998, 2000a, 2000b) suggests that despite disparate views presented in these research studies, both perspectives accommodate the notion that parenting patterns may be discussed within the Baumrind's parenting styles framework. My own application of Baumrind’s model to the Turkish social context will be discussed in detail in a different article.

As I mentioned above, we should focus on how to improve the parenting skills to help the child to overcome the problems related to ADHD. Other than psychiatric neuro-biological dominance, there are two major difficulties ahead: One is the negligence and lack of knowledge/ignorance of psychologists, the other is the fragility/sensitivity of parents (mostly mothers). As comprehensively discussed in Singh's (2004) article, in a culture (actually in cultures) of mother-blame, mothers are desperately trying to do their jobs without the back lash of accusations. Neuro-biological explanations and medical interventions serve the purpose of easing their guilt/souls. It is our duty to overcome this problem and include their specific knowledge in our research in order to produce successful results in a short span of time. Once they witness that the approach works almost immediately (to compete with the immediate effect of stimulants), I believe they wouldn't hesitate to proceed with it since the results will be proof of their personal efforts without the help of medication.

References

Angold, A., Erkanli, A., Egger, E., and Costello, J. (2000). Stimulant treatment for children: a community perspective. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 975-994.

Chen, X., Dong, Q., and Zhou, H. (1997). Authoritative and authoritarian parenting practices and social and school performance in Chinese children. International Journal of Behavioral Development, 21, 855–873.

Goodman, R., and Stevenson, J. (1989). A twin study of hyperactivity – II. The aetological role of genes, family relationships and perinatal adversity. Journal of Child Psychology and Psychiatry, 30(5), 691-709

Rowland-Klein, D., and Dunlop, R. (1998). The transmission of trauma across generations: Identification with parental trauma in children of Holocaust survivors. Australian and New Zealand Journal of Psychiatry, 32, 358-369.

Singh, I. (2004). Doing their jobs: mothering with Ritalin in a culture of mother-blame. Social Science and Medicine, 6, 1193-1205.